Providing patients the right care at the right time has achieved new levels of attention in healthcare delivery. For diagnostic and therapeutic procedures, this includes ensuring proper patient selection, given that procedural benefits may not exist for some patients despite significant clinical risk and cost. The importance of proper patient selection is reflected in the efforts of the Choosing Wisely campaign and Appropriate Use Criteria that seek to reduce the use of medical tests and procedures that may be inappropriate (i.e. provide no patient benefit despite procedural risk). Few contemporary data exist on whether invasive and expensive diagnostic and therapeutic procedures are used inappropriately in the VA. We seek to address this critical knowledge gap as it relates to the care of patients with coronary artery disease (CAD), a common and high cost clinical condition in the VA. In the care of Veterans with CAD, more than 10,000 percutaneous coronary interventions (PCI) and 50,000 stress tests are performed annually. These procedures are appropriate in symptomatic CAD patients for diagnostic evaluation and symptom reduction. However, use of these procedures in asymptomatic CAD patients without significant ischemic or coronary disease burden is inappropriate and results in unnecessary procedural risks of myocardial infarction, bleeding, renal failure, radiation exposure, and death. Additionally, these procedures are expensive and contribute more than $200 million in healthcare expenditures annually to the VA. In pilot chart review, 1 in 10 PCI and stress tests performed in the VA for stable CAD were inappropriate, suggesting 6,000 Veterans may undergo unnecessary cardiovascular procedures at a cost of $20 million annually. The prevalence, patient risks, and expense of these procedures demand further investigation to an understanding whether they are being used for the appropriate patient populations in the VA. Furthermore, in an era where the VA is increasingly asked to do more with less, it is critical to determine if inappropriate use of these procedures is a significant contributor to unnecessary costs in low-value care. Accordingly, the fundamental goal of this proposal is to determine the extent of inappropriate use of PCI and stress tests performed in the VA for patients with CAD and whether inappropriate use is a major contributor to low-value healthcare. Informed by these analyses, we will then conduct qualitative research to identify best-practices for the delivery of appropriate and high-value care. The proposal's 3 aims will: 1) assess the rate of PCI and stress tests performed in asymptomatic patients classified as inappropriate by the Appropriate Use Criteria across the VA healthcare system and identify patient, provider, and environmental factors associated with inappropriate use; 2) determine the extent of variation in healthcare value that is attributable to inappropriate use of PCI and stress tests in asymptomatic patients; and 3) identify best-practices for appropriate procedural use and high-value healthcare through key informant interviews at outlier hospitals as determined by rates of inappropriate use and costs relative to patient outcomes. We will answer these questions in a cohort of 20,000 patients with CAD identified at coronary angiography performed between 2011 and 2013 using data from the VA National Clinical Assessment Reporting and Tracking (CART) Program linked to VA administrative data sources. Among CAD patients who undergo subsequent PCI and stress tests after PCI, we will complete chart review to determine procedural appropriateness while concurrently developing methods to allow prospective appropriateness measurement. In the determination of healthcare value following the diagnosis of CAD, we will include overall costs of care and clinical outcomes of mortality and non-fatal myocardial infarction. In the future, this proposal's findings will directly enhance Veterans' care by 1) providing strategies to achieve appropriate and high-value care for patients with CAD and 2) serving as a model to address other areas of high-utilization, high-cost care delivery.